Case Report
J Clin Ultrasound 203324426, NovembedDecember 1992 CCC 0091-2751/92/090624-03 0 1992 by John Wiley & Sons, Inc.
Ultrasonography in the Recognition of Penile Cancer A. Cengaver Dorak, MD, G. Ajlan Ozkan, MD, Nevin I. Tamac, MD, and Ayse Saray, MD
Ultrasound scanning is considered to be ideally suited for the evaluation of lesions of the penis because penile tissue transmits ultrasonic beams perfectly due to the lack of gas and bone.’ There are, however, only a few reports on ultrasonographic diagnosis of mass lesions of the penis including hematoma,ls2 a b s ~ e s s ,and ~ ~ a n c e r in ,~ contrast to a large number of papers on its use in vasculogenic i m p ~ t e n c e , urethral ~ strictures,6 and Peyronie’s disease.” In the present report, we describe the sonographic features of a patient with penile cancer. The diagnostic value of sonography is compared with other imaging methods such as cavernosography and computed tomography. CASE REPORT
A 65-year-old man with a 2-month history of pain and swelling in the penis was referred for
From the Department of Radiology, Ankara State Hospital, Ankara, Turkey. For reprints contact Ayse Saray, MD, Genclik Mah. 1315. Sok., 49/10 Antalya, Turkey.
retrograde urethrography and cavernosography. In retrograde urethrography, ventral displacement of the midportion of the penile urethra was observed. Cavernosography showed a filling defect in the proximal half of the penile shaft (Figure 1). Subsequently, ultrasound examination was performed to identify the nature of the lesion. Ultrasonography revealed a hypoechoic, homogeneous tumor in the proximal shaft of the penis confined to both corporeal bodies. The septum penis was intact (Figure 2). At this stage, the patient refused surgical intervention. Two months later, the patient was admitted to the hospital because of increased pain and swelling. In a repeat ultrasonic examination, expansion of the mass was detected along almost the entire penile shaft. The lesion had a more complex echo pattern characterized by predominance of multiple, hypoechoic nodular areas and invasion of the septum penis (Figure 3). In sonourethrographic examination, following distension of the urethra with saline, slight compression of the urethra and invasion Of the corpus spongiosum in its dorsal aspect were observed (Figure 4). The sonographic appearance was suggestive of a highly
A
B FIGURE 1. (A) Retrograde urethrogram demonstrating ventral displacement of the penile urethra secondary to a mass. (B) Cavernosography re. vealed a filling defect in the proximal half of the penis.
624
RECOGNITION OF PENILE CANCER
FIGURE 2. Coronal sonogram of the base of the penis showing a homogenous solid mass ( M I involving both the corpus cavernosum and the dense stripe between them corresponding t o the septum penis (arrows). The proximal area is on the right side and the distal area on the left.
aggressive malignant neoplasm, with striking change in echo structure, progressive increase in size, and invasion by the mass in the second examination. Computerized tomography of the penis displayed an ill-defined, hypodense, spaceoccupying mass lesion (Figure 5). During the operation for amputation, the patient had a cardiac arrest and died. Postmortem examination re-
625
FIGURE 3. Follow-up sonography made in sagittal plane revealed a nonhomogenous tumor mass invading a large portion of the penile shaft. The transducer is ventral. The root of the penis is on the right and the glans penis is on the left ( S ; corpus spongiosum).
vealed that the lesion was a sarcomatous neoplastic mass. DISCUSSION
Primary and secondary neoplasms of the penis are very raree8-l0Metastatic tumors of the penis usually originate from the urinary or gastrointestinal the corpora cavernosa
FIGURE 4. Sonographic urethrogram demonstrating a relationship between the mass and urethra (arrows) associated with invasion of the corpus spongiosum in its dorsal aspect. The transducer is ventral. (A) Longitudinal sagittal view of the penile shaft. (6) Transscrotal sagittal view of the base of the penis (CY, incidental left epididymal cyst). (C) Transverse sonogram at the level of the midportion of the penile shaft. VOL. 20. NO. 9, NOVEMBERiDECEMBER 1992
626
CASE REPORT: DORAK ET AL.
evaluate urethral strictures,6 proved to be useful in the demonstration of the invasion at the dorsal aspect of the corpus spongiosum and also the compression of the urethra by the mass. In conclusion, meticulous ultrasonography in combination with sonourethrography may provide reliable information for the initial diagnosis and follow-up of penile cancer in a noninvasive way. We believe ultrasonography will be increasingly used in the diagnosis of space-occupying penile lesions. REFERENCES
FIGURE 5. Cross-sectionalcomputed tomography image of the penis showing an ill-defined, hypodense mass.
being the most common site of involvement." The diagnostic methods of choice for penile cancer are cavernosography and biop~y.'~'' To date, ultrasonography and computed tomography have not been widely used in the evaluation of this neoplasm. Only Yamashita and Ogawa4 used ultrasonography in 2 patients to examine local extension and regional lymphatic spread of cancer originating from the glans penis. To our knowiedge, there is no previous report of penile cancer located in the corpus cavernosum diagnosed sonographically. In the patient reported here, cavernosography and computed tomography revealed the lesion, but failed to clarify the nature of the mass. However, ultrasonographic findings were consistent with a neoplastic mass and repeat examinations suggested that it was an aggressive tumor. The finding of an intact septum penis despite the invasion of both corporeal bodies in the initial investigation was suggestive of metastasis (Figure 2). However, the clinical course did not confirm this possibility. Sonographic urethrography, which was originally introduced as a method to
1. Forman HP, Rosenberg HK, Snyder HM 111: Fractured penis: Sonographic aid to diagnosis. AJR 153:1009, 1989. 2. Dierks PR, Hawkins H: Sonography and penile trauma. J Ultrasound Med 2:417, 1983. 3. Niedrach WL, Lerner RM, Linke CA: Penile abscess involving the corpus cavernosum: A case report. J Urol 141:374, 1988. 4. Yamashita T, Ogawa A: Ultrasound in penile cancer. Urol Radiol 11:174, 1989. 5. Benson CB, Vickers MA: Sexual impotence caused by vascular disease: Diagnosis with duplex sonography. AJR 153:1149, 1988. 6. Gluck CD, Bundy AL, Fine C, et al: Sonographic urethrogram: Comparison to roentgenographic techniques in 22 patients. J Urol 140:1404, 1988. 7. Princivalle M, Sirnone M, De Luca C, et al: Echographic diagnosis of Peyronie's disease. Radiol Med (Torino) 78:74, 1989. 8. Dehner LP, Smith BH: Soft tissue tumors of the penis. A clinicopathologic study of 46 cases. Cancer 25:1431, 1970. 9. Ucar JA, Robles JE, Isa WA, et al: Secondary carcinoma of the penis. A report of three new cases. Eur Urol 16:308, 1989. 10. Robey EL, Schellhammer PF: Four cases of metastases to the penis and a review of the literature. J Urol 132:992, 1984. 11. Raghavaiah NV: Corpus cavernosogram in the evaluation of carcinoma of the penis. J Urol 120:423, 1978.
JOURNAL OF CLINICAL ULTRASOUND
J Clin Ultrasound 203324426, NovembedDecember 1992 CCC 0091-2751/92/090624-03 0 1992 by John Wiley & Sons, Inc.
Ultrasonography in the Recognition of Penile Cancer A. Cengaver Dorak, MD, G. Ajlan Ozkan, MD, Nevin I. Tamac, MD, and Ayse Saray, MD
Ultrasound scanning is considered to be ideally suited for the evaluation of lesions of the penis because penile tissue transmits ultrasonic beams perfectly due to the lack of gas and bone.’ There are, however, only a few reports on ultrasonographic diagnosis of mass lesions of the penis including hematoma,ls2 a b s ~ e s s ,and ~ ~ a n c e r in ,~ contrast to a large number of papers on its use in vasculogenic i m p ~ t e n c e , urethral ~ strictures,6 and Peyronie’s disease.” In the present report, we describe the sonographic features of a patient with penile cancer. The diagnostic value of sonography is compared with other imaging methods such as cavernosography and computed tomography. CASE REPORT
A 65-year-old man with a 2-month history of pain and swelling in the penis was referred for
From the Department of Radiology, Ankara State Hospital, Ankara, Turkey. For reprints contact Ayse Saray, MD, Genclik Mah. 1315. Sok., 49/10 Antalya, Turkey.
retrograde urethrography and cavernosography. In retrograde urethrography, ventral displacement of the midportion of the penile urethra was observed. Cavernosography showed a filling defect in the proximal half of the penile shaft (Figure 1). Subsequently, ultrasound examination was performed to identify the nature of the lesion. Ultrasonography revealed a hypoechoic, homogeneous tumor in the proximal shaft of the penis confined to both corporeal bodies. The septum penis was intact (Figure 2). At this stage, the patient refused surgical intervention. Two months later, the patient was admitted to the hospital because of increased pain and swelling. In a repeat ultrasonic examination, expansion of the mass was detected along almost the entire penile shaft. The lesion had a more complex echo pattern characterized by predominance of multiple, hypoechoic nodular areas and invasion of the septum penis (Figure 3). In sonourethrographic examination, following distension of the urethra with saline, slight compression of the urethra and invasion Of the corpus spongiosum in its dorsal aspect were observed (Figure 4). The sonographic appearance was suggestive of a highly
A
B FIGURE 1. (A) Retrograde urethrogram demonstrating ventral displacement of the penile urethra secondary to a mass. (B) Cavernosography re. vealed a filling defect in the proximal half of the penis.
624
RECOGNITION OF PENILE CANCER
FIGURE 2. Coronal sonogram of the base of the penis showing a homogenous solid mass ( M I involving both the corpus cavernosum and the dense stripe between them corresponding t o the septum penis (arrows). The proximal area is on the right side and the distal area on the left.
aggressive malignant neoplasm, with striking change in echo structure, progressive increase in size, and invasion by the mass in the second examination. Computerized tomography of the penis displayed an ill-defined, hypodense, spaceoccupying mass lesion (Figure 5). During the operation for amputation, the patient had a cardiac arrest and died. Postmortem examination re-
625
FIGURE 3. Follow-up sonography made in sagittal plane revealed a nonhomogenous tumor mass invading a large portion of the penile shaft. The transducer is ventral. The root of the penis is on the right and the glans penis is on the left ( S ; corpus spongiosum).
vealed that the lesion was a sarcomatous neoplastic mass. DISCUSSION
Primary and secondary neoplasms of the penis are very raree8-l0Metastatic tumors of the penis usually originate from the urinary or gastrointestinal the corpora cavernosa
FIGURE 4. Sonographic urethrogram demonstrating a relationship between the mass and urethra (arrows) associated with invasion of the corpus spongiosum in its dorsal aspect. The transducer is ventral. (A) Longitudinal sagittal view of the penile shaft. (6) Transscrotal sagittal view of the base of the penis (CY, incidental left epididymal cyst). (C) Transverse sonogram at the level of the midportion of the penile shaft. VOL. 20. NO. 9, NOVEMBERiDECEMBER 1992
626
CASE REPORT: DORAK ET AL.
evaluate urethral strictures,6 proved to be useful in the demonstration of the invasion at the dorsal aspect of the corpus spongiosum and also the compression of the urethra by the mass. In conclusion, meticulous ultrasonography in combination with sonourethrography may provide reliable information for the initial diagnosis and follow-up of penile cancer in a noninvasive way. We believe ultrasonography will be increasingly used in the diagnosis of space-occupying penile lesions. REFERENCES
FIGURE 5. Cross-sectionalcomputed tomography image of the penis showing an ill-defined, hypodense mass.
being the most common site of involvement." The diagnostic methods of choice for penile cancer are cavernosography and biop~y.'~'' To date, ultrasonography and computed tomography have not been widely used in the evaluation of this neoplasm. Only Yamashita and Ogawa4 used ultrasonography in 2 patients to examine local extension and regional lymphatic spread of cancer originating from the glans penis. To our knowiedge, there is no previous report of penile cancer located in the corpus cavernosum diagnosed sonographically. In the patient reported here, cavernosography and computed tomography revealed the lesion, but failed to clarify the nature of the mass. However, ultrasonographic findings were consistent with a neoplastic mass and repeat examinations suggested that it was an aggressive tumor. The finding of an intact septum penis despite the invasion of both corporeal bodies in the initial investigation was suggestive of metastasis (Figure 2). However, the clinical course did not confirm this possibility. Sonographic urethrography, which was originally introduced as a method to
1. Forman HP, Rosenberg HK, Snyder HM 111: Fractured penis: Sonographic aid to diagnosis. AJR 153:1009, 1989. 2. Dierks PR, Hawkins H: Sonography and penile trauma. J Ultrasound Med 2:417, 1983. 3. Niedrach WL, Lerner RM, Linke CA: Penile abscess involving the corpus cavernosum: A case report. J Urol 141:374, 1988. 4. Yamashita T, Ogawa A: Ultrasound in penile cancer. Urol Radiol 11:174, 1989. 5. Benson CB, Vickers MA: Sexual impotence caused by vascular disease: Diagnosis with duplex sonography. AJR 153:1149, 1988. 6. Gluck CD, Bundy AL, Fine C, et al: Sonographic urethrogram: Comparison to roentgenographic techniques in 22 patients. J Urol 140:1404, 1988. 7. Princivalle M, Sirnone M, De Luca C, et al: Echographic diagnosis of Peyronie's disease. Radiol Med (Torino) 78:74, 1989. 8. Dehner LP, Smith BH: Soft tissue tumors of the penis. A clinicopathologic study of 46 cases. Cancer 25:1431, 1970. 9. Ucar JA, Robles JE, Isa WA, et al: Secondary carcinoma of the penis. A report of three new cases. Eur Urol 16:308, 1989. 10. Robey EL, Schellhammer PF: Four cases of metastases to the penis and a review of the literature. J Urol 132:992, 1984. 11. Raghavaiah NV: Corpus cavernosogram in the evaluation of carcinoma of the penis. J Urol 120:423, 1978.
JOURNAL OF CLINICAL ULTRASOUND
